Healthcare Provider Details

I. General information

NPI: 1457903841
Provider Name (Legal Business Name): CHIVON FORRESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9029 S PECOS RD STE 2700
HENDERSON NV
89074-7198
US

IV. Provider business mailing address

10000 S MARYLAND PKWY APT 2019
LAS VEGAS NV
89183-6389
US

V. Phone/Fax

Practice location:
  • Phone: 702-680-1526
  • Fax:
Mailing address:
  • Phone: 201-686-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35654
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: